AIDS and Condoms: The Science

Scores of
commentators, journalists and politicians heaped scorn on Pope Benedict XVI for
his response in a March 17 press interview: The AIDS epidemic in Africa “can’t
be resolved with the distribution of condoms: On the contrary, there is a risk
of increasing the problem.”

Bonnie Erbe, writing in U.S.
News & World Report, called his remark “one of the most
horrifically ignorant statements.” The Lancet medical
journal, which has published a number of (apparently forgotten) studies supportive
of the Pope’s assertion, editorialized that his comments were “outrageous and
wildly inaccurate.”

And a March 19 Washington
Post editorial pontificated: “Everyone is entitled to his own
opinion, but not his own facts.”

There’s rich irony here: All the
ignorance, inaccuracies and subjective “facts” belong to Benedict’s detractors.
The Holy Father’s contention that condoms may be counterproductive in combating
the AIDS pandemic in Africa is solidly backed by a growing body of empirical
research published over the past 15 years.

True believers in the core tenets of
the sexual revolution — that contraceptives take all the risk out of casual sex
— are baffled that a technology that works well under laboratory conditions
fails miserably in real-life use. Given the fact that everyone agrees that
condoms are the least effective
contraceptive for pregnancy prevention, it is a mystery why condom promoters
consider them the state-of-the-art best defense against HIV transmission.

There are many reasons why massive
distribution of condoms fails to stop HIV transmission, including
risk-compensation behavior, inconsistent use, method and user errors, and
cumulative risk.

Risk compensation describes an
interesting behavioral pattern in humans — a greater willingness to engage in
potentially risky behavior when one believes his risk has been reduced through
technology. For example, someone who uses sunscreen is likely to stay in the
sun longer, and studies have in fact shown an increase in melanoma among
sunscreen users due to their longer exposure.

After mandatory seat-belt laws were
introduced in the United Kingdom, traffic fatalities surprisingly increased:
“In the 23 months that followed the introduction of the U.K. seat-belt law, the
number of deaths among pedestrians, cyclists, and unbelted rear seat passengers
rose by 8%, 13% and 25% respectively,” due to faster and riskier driving.

John Richens et al., writing in The
Lancet, then suggest three ways that a substantial increase in
condom use could nevertheless fail to reduce disease transmission: “First,
condom promotion appeals more strongly to risk-averse individuals who contribute
little to epidemic transmission. Second, increased condom use will increase the
number of transmissions that result from condom failure. Third, there is a
risk-compensation mechanism: Increased condom use could reflect decisions of
individuals to switch from inherently safer strategies of partner selection or
fewer partners to the riskier strategy of developing or maintaining higher
rates of partner change plus reliance on condoms.”

Conclusion: “A vigorous
condom-promotion policy could increase rather than decrease unprotected sexual
exposure, if it has the unintended effect of encouraging greater sexual
activity.”

Michael Cassell and colleagues,
writing in the British Medical Journal in 2006, also have
focused on how risk-compensation behaviors blunt the effectiveness of new
technological measures to combat the AIDS epidemic. They note the findings of
many HIV researchers: that “the perception that using condoms can reduce the
risk of HIV infection may have contributed to increases in inconsistent use,
which has minimal protective effect, as well as to a possible neglect of the
risks of having multiple sexual partners. Thus, the protective effect of
promoting condoms may be attenuated at the population level and could even be
offset by aggregate increases in risky sexual behavior” (emphasis
added).

Cassell
cites numerous studies showing that the availability of antiretroviral drugs
and expanded access to treatment have resulted in significant increases in
risky behavior among homosexual men and injecting drug users in Europe, the
United States and Australia. Therefore, the authors stress that “behavior
change” (abstinence, monogamy or fewer partners), which has proven “a feasible
and effective approach to preventing new HIV infections,” must be promoted as
an integral part of any HIV/AIDS prevention program.

In an interview with Christianity
Today, Edward Green, director of the AIDS Prevention Research
Project at the Harvard Center for Population and Development Studies,
vigorously defended Pope Benedict’s contention that condoms may increase HIV
transmission in Africa: “The best evidence we have supports his comments.” He
adds, “There’s no evidence at all that condoms have worked as a public health
intervention intended to reduce HIV infections at the ‘level of population.’ …
Major articles published in Science, The
Lancet, British Medical Journal,
and even Studies in Family Planning have reported
this finding since 2004.”

Green reports that in eight or nine
African countries, HIV has declined and, in every case, “there’s been a
decrease in the proportion of men and women reporting multiple sexual partners.
Ironically, in the first country where we saw this, Uganda, HIV prevalence
decline stopped in 2004, and infection rates appear to be rising again. … in
part because emphasis on interventions that promote monogamy and fidelity has
weakened significantly, and earlier behavior changes have eroded. … [and]
foreign donors have persuaded Uganda to put even more emphasis on condoms.”

In his 2003 book, Rethinking
AIDS Prevention: Learning From Successes in DevelopingCountries,
Green cites numerous studies finding “higher rates of STD or HIV infections
among inconstant condom users than among condom nonusers. … And, of course,
condom use is inconsistent far more often than it is consistent, virtually
everywhere.”

He explains that condoms “might give
some men a somewhat greater sense of security than warranted by actual condom
effectiveness. This might lead to more risky sexual behavior than men might
practice if condoms were not available.”

He adds that in the real world
“Third World situations, where use may not be correct, or condoms may be of
poor or deteriorated quality, made of non-latex, or the wrong size [leading to
slippage or tearing], protection may be actually less than 80%, even when use
is consistent, which is rare.”

Cumulative risk exposure with
condoms is overlooked.

Cumulative risk is a simple concept:
One’s risk of infection increases with increasing numbers of condom-“protected”
exposures. J. Thomas Fitch et al. (2002) note that “an intervention that is
99.8% effective for a single episode of intercourse can yield an 18% cumulative
failure rate with 100 exposures.” As applied to condoms, Green gives a
straightforward illustration of cumulative risk: With “repeated exposures to an
infected partner, such as a man visiting a sex worker [sic] in Nairobi or
Johannesburg once a month, the man will likely be infected within five months,
even with consistent condom use.”

Due to cumulative risk, R. Gordon noted
in 1989 that condoms provide inadequate risk reduction for individuals, as it
is statistically quite likely that a condom user who engages in casual sex or
sex with people likely to be infected with HIV/AIDS will eventually become HIV
infected, as well.

What works?

James Shelton, a USAID senior
medical scientist, co-authored a 2004 study in the British
Medical Journal explaining the “crucial role” of partner reduction
in reducing HIV/AIDS transmission. Partner reduction was critical in Uganda and
elsewhere. While he does not dismiss the role of condoms in specific
circumstances, he cautions: “Even though prospective studies have shown that
condoms reduce risk by about 80%-90% when always used, in real life they are
often used incorrectly and inconsistently. They should therefore not be
advertised in a manner that leads to overconfidence or risky behavior.”

Also in 2004, Tim Allen of the
London School of Economics and Suzette Heald of Brunel University collaborated
on an article explaining how the early aggressive promotion of condoms doomed
efforts to curb HIV/AIDS in Botswana, while the resistance to condom promotion
in Uganda fostered behavior changes that dramatically reversed the epidemic in
Uganda.

Although the reproductive “rights”
and pharmaceutical industries continue to propagate the conventional wisdom
that widespread consistent condom use is the key to halting the transmission of
HIV/AIDS, approximately 150 experts signed a statement — again in TheLancet
— in 2004 calling for a “common ground,” evidence-based approach to
preventing the sexual transmission of HIV/AIDS with primary emphasis on
behavior-modification in generalized epidemics.

The lead authors, Daniel Halperin et
al., prioritize interventions according to their effectiveness in dealing with
the target audience and the type of epidemic (generalized, as in sub-Saharan
Africa, or one mainly among “commercial sex workers [sic]” and their clients in
Thailand and Cambodia):

“When targeting young people … the
first priority should be to encourage abstinence or delay of sexual onset. …
After sexual debut, returning to abstinence or being mutually faithful with an
uninfected partner are the most effective ways of avoiding infection.”

They continue: “When targeting
sexually active adults, the first priority should be to promote mutual fidelity
with an uninfected partner as the best way to assure avoidance of HIV
infection. The experience of countries where HIV has declined suggests that
partner reduction is of central epidemiological importance in achieving
large-scale HIV incidence reduction.”

Once again, science has proven the
wisdom of Church teaching on abstinence before, and faithfulness within,
marriage. Once again, Benedict was right!

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